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HomeMy WebLinkAbout0088 LAKEVIEW DRIVE �. .3 t k s Z+ {3 3 4 3 t i 1 u P icalion number...��� . ... ........... ... ................... .. ..... ......... M Building Inspectors Initials.. 'tQ1Q Date Issued......,.1...3.1...1.21*....................... Map/Parcel... `� `®TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: g L � U NUMBER �(( STREET VILLAG Owner's Name: 1 C T `'✓� Phone Number -1 C� - 5<-75-L Email Address: Cell Phone Number Project cost$ �l (� Check one Residential Commercial. OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application fora g permit in_axFordance withh 80 CMR Owner Signature: / Date: TYPE OF WORK © Siding 0 Windows (no header change)# F-1 Insulation/Weatherization 0 Doors(no header change) # Commercial Doors require an inspector's review E 1 Roof(not applying more than 1 layer of shingles) ^ Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name ''G 1 `tl\ CCU Home Improvement Contractors Registration if applicable)# f (attach copy) Construction Supervisor's License#_ I O 2- S (attach copy) Email of Contractor 0 10,�'/'kIQEhonnumber C-D 6rr 2- ALL PROPERTIES THAT HAVE STRUCTURES 6VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tents will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X. X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No ,if yes, a gas permit is required. Natural Gas Yes No ,if yes,a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date 0- All permit applications are subject to a building.official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ 600 Washington Street 'Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Le 'bI Name(Business/Organization/Individual): Address: Q City/State/Zip: (s-) �- 1 � Phone#: U r S — S 2 Are you employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building,addition [No workers'comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its IO.❑Electrical repairs or additions 3.El officers have exercised their I am a homeowner doing all work 11.❑Plumbing repairs or additions myself o workers' right of exemption per MGL y � comp. 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suck Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state Whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. . I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /� Insurance Company Namek\ C1 Ct ✓1 ` Cil/t C- Policy#or Self-ins.Lie.#: U 2 C— t�L l 2 C Expiration Date: S Job Site Address:, U �- lC C l3 L�z U0 l� City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: d' Z 6— 5 S 2— Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector. 6.Other Contact Person: Phone#: Information and Instructions, Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an anTloyee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not prod uced'acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to-your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of urn _cl wild vnT,_have_aav questions regarding the law or if you are required to obtain a workers' compensation policy,please-c ailthe Department at the number listed below. Self-insured companies showa finer-Lneir self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitilicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number- The,Commonwealth:.of Massaohuwtts Depai t nent of Industrial AcddOuts Office of Investigations 600 Washington Beet Boston,MA 02111 Tel. 617-727-4900 ext 406 or 1-K77-MASSAF., Fax#6.17-727-7749 Revised 4-24-07 www.r =,gov/dia a Office of Consumer Affairs&6usiness Regulation HOME IMPROVEMENT CONTRACTOR TY. n 02/11/2020 ALL ROOFING'f1 S _ T, INC ANDREW WILL MS m 'S 210 W EST RD WELLFLEET,MA. M 7 Undersecretary Massac:huseft Departrnent of Pu6jic,Saf4ty .�M I V-F - Board of 8uildfng Regulations and.Standaids License: C$=1058 #* Construction,Supery sdr " A, ANDREWWR.t.1AAAS 210 WEST RQAp,2-0, ' WELLFLEET MA_IO2i1�'I ,� i.% /�''r�a.�--• Explr`a'tion: Commissio er' 02/02/2018 1Y / - J Page If of pages s: 4. AN0"AL ILLIAMS ROOFING& CONTRACTING PO.BOX 517 EASTHAM9 MA PROPOSAL SUBM]ITEIR JOB NAME JOB# P) C) AJ ADDRESS JOB LOCATION ter- G v \� l DATEDATE OF PLANS PHONE# � � I S�� _� ` _C FAX# d ARCHITECT Ve hereby submit specifications and estimates for: ..... ._.. tM21/� � 2 L4 -j__ 1 a. 1��C)I j l� Q , _ L2_ _........_... -.-.................____ ............... -__----------___................_______ Ve propose herebyto furnish material and labor—complete in accordance with the above specifications for the sum of: l �7 G c Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs Respectfully will be executed only upon written order,.and will become an extra charge Submitted over and above the estimate. All agreements contingent upon strikes, ^1 accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. Rcceptance ®f Propozat The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Signature' Date of Acceptance f Signature _j/1 A-NC3819/T-3850 09-11 ' r ALLRO-1 op in. min DATE(MMIDDIYYYY) dcoao° CERTIFICATE OF LIABILITY INSURANCE s ��04/04/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER 508-255-8000 RRWCT W.Scott Kerry Kerry Insurance Agency Inc, PHONE 508-255-8000 FAX 508-240-1860 P.0.Box 1945 ICNoo Ext� _ _ (A/c,No): _ N.Eastham,MA 02651 R lkss_kerry@c4.net N.Scott Kerry _ INSURER(S)AFFORDING COVERAGE NAIC# _ INSURER A,Western World Insurance Co INSURED All Roofing&Contracting Inc. P.0.Box 517 — -- —--_— ����----- Eastham,MA02642 INSURERC,: ' INSURERD_ INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OFlNSURANCE ADDL SUBR POLICY NUMBER I POLICY EFF POLICY EXPITR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR INPPS467331 03/04/2018 03/04/2019 DAM AGE S(Ea occurfence) RENTED 1OO,000 $ 1 5,000 ( k MED EXP(Any oneperson] $ I f PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 1 j I GENERAL AGGREGATE $ 2,000,000 X . ; � I 2,000,000 POLICY JPRpT LOC PRODUCTS-COMPIOP AGG $ - OTHER: AUTOMOBILE LIABILITY I I 1Ea aBciden�INGLE'LIMIT $ I ANY AUTO 1 ( 1 BODILYINJURY Per erson 1$ OWNED SCHEDULED I` i-----_ 1_�_��_ AUTOS ONLY AUTOS ` ( 1 BODILY INJURY Per accident $ AURE N yy PROPERTY DAMAGE TOS ONLY AUOT, 'ONE i (Per accident) 1 ! ! i UMBRELLA LU1B OCCUR , 1 EACH OCCURRENCE EXCESS LIAS CLAIMS-MADE ! AGGREGATE__ $ DEC) RETENTION$ I ! $ WORKERS COMPENSATION , .. —lam ER OTH- — AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIV E.L.EACH ACCIDENT I$ OFFICER/MEMBER EXCLUDED?? j—�I N I A (Mandatory in NH) f , I E.L.DISEASE-EA EMPLOYE $_ H yes,describe under (. I 3 E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below I i DESCRIPTION OF OPERATIONS ROGATIONS I VEHICLES(ACORD i 0i,Additional Remarks Schedule,may be attached if more space is required) Roofing,siding,carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC40[7R ® CERTIFICATE OF LIABILITY INSURANCE °ATE`MM/°°m"' 10/25/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT AAME: W Scott Kerry, KERRY INSURANCE AGENCY PHONE , (508)255-8ot)o ac No: ADDRESS: scoft@kerryinsurance.com P O BOX 1945 - INSURERS AFFORDING COVERAGE NAIC• N.EASTHAM MA 02651 INSURERA: AMGUARD INSURANCE CO 42390 INSURED INSURER 8: ALL ROOFING &CONTRACTING INC INSURERC: INSURER D: PO BOX 517 INSURER E: EASTHAM MA 02642 INSURER F: COVERAGES CERTIFICATE NUMBER: 330106 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCEDLSUBR POLICY EFF POLICY EXP LIMITS LTR POLICYNUMBER MM/DD MM/DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ O E TE CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A - PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $. POLICY aJEC LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY - COMBINEDSINGLEDMIT $ Ea accident ANY AUTO BODILY INJURY(Per person). $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPER' nOAMAGE $ HIREDAUTOS AUTOS UMBRELLAUAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY /� STATUTE EORµ _ ANYPROPRIETOR/PARTNER/EXECUTIVE- Y/N E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? NIA NIA NIA R2WC998421 05/17/2018 05/17/2019 -- (Mandatory In NH) - E.L.DISEASE-EA EMPLOYEE $ 100,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers'Compensation benefits Will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03`06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification. Search tool at www.inass.gov/lwd/workers-compensation/investigations/. 'CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN - ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel M.Cro4¢ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD